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December 4th, 2013
Freethought San Marcos: The debates of 1787 foreshadowed today’s health care debate

Freethought San Marcos: A column


If the Social Security debate is a reliable precursor of the debate over the Patient Protection and Affordable Care Act (ACA), a/k/a Obamacare, we will likely be debating the subject when my 9-year old grand-daughter is ready to retire.

A recent commentary by America’s leading consumer advocate (I won’t mention his name for fear of creating a disturbance among some of my friends) caused me to think again about a topic I wrote about often in 2009, and occasionally since then.

Every couple of days, it seems, someone asks me what I think of Obamacare.  It is difficult to give a one sentence response that conveys adequately my views on a complicated subject.  I did not support the ACA until I knew that it was all we were going to get.  Then, I supported it only because it was better than what we had (and still have) in a country that most Americans believe is exceptional.

We seem unexceptional regarding health care, compared to those countries with universal or near-universal benefits:  Australia, Austria, Belgium, Canada, Denmark, England, Finland, France, Germany, Greece, Iceland, Israel, Italy, Japan, Luxembourg, Netherlands, New Zealand, Northern Ireland, Norway, Portugal, Russian Federation, South Korea, Scotland, Spain, Sweden, Switzerland, Taiwan, Wales, and others.

The World Health Organization’s World Health Report 2000 – Health Systems: Improving Performance compared health care systems in countries based on good health, responsiveness to the expectations of the population, and fair financial contribution.  Australia, Canada, France, Germany, Italy, Japan, Norway, Sweden, and the United Kingdom (England, Scotland, Northern Ireland, Wales) all were ranked better on nearly all measures than the United States.

All of those countries had greater life expectancies, lower infant mortality rates, and less spending of government money (as a percentage of expenditures as a whole) on health care.  All but two of those countries had more physicians per 100,000 people.  But the most startling figures may be that in the United States, per capita spending on health care is about twice that of all these other countries taken together, and more of it comes from the government than in any of these countries with better-performing universal health care systems, yet 82 million people in the US don’t have access to adequate health care.  For many, the only access is an emergency room.

The main reason we will continue to argue about the ACA and health care in general in this country relates back to the original split between our founders over the proper role of government.  The founders who wrote the Constitution were called Federalists.  They included George Washington, Alexander Hamilton, James Madison, and Gouverneur Morris (named after his mother’s birth name – she was Sarah Gouverneur).

This group has been called “pragmatic nationalists” – they wanted a system that gave the national government sufficient power to help the country succeed, as it had not done under the Articles of Confederation, which gave most of the power to the states.  A reading of the Constitution makes clear that these Federalists were concerned that the country be organized to function well as a whole and to allow commerce to develop and flow freely within the country and between the new country and other countries.

To accomplish these and other important purposes, the Constitution set out numerous specific powers.  Last, but certainly not least, was that the federal government was to have the authority to pass laws that the Congress deemed “necessary and proper” (see Article I, Section 8, Clause 18).  And among those enumerated powers is to provide “for the general Welfare,” echoing the phrase “promote the general Welfare” found in the Preamble.

As Steven Calabrisi wrote in the Harvard Journal of Law & Public Policy, “. . . the Necessary and Proper Clause grants Congress sweeping power to enact laws it reasonably believes necessary to carry out the national government’s other powers; as long as Congress’s action falls within the fair range of the Constitution’s text, judges are not empowered to strike it down.”

Yet, the anti-Federalists – what could be termed the right-wing today – did not want the federal government to be given such broad powers.  Sixteen of those men at the 1787 Constitutional Convention did not sign the document.  One of them, Robert Yates, wrote that Article I, Section 8 went too far:

“This government is to possess absolute and uncontrollable power, legislative, executive and judicial, with respect to every object to which it extends . . . It has the authority to make laws which will affect the lives, the liberty, and the property of every man in the United States; nor can the constitution or the laws of any state, in any way prevent or impede the full and complete execution of every power given.”

Yates believed, as he stated in a joint letter with John Lansing to the Governor of New York explaining their withdrawal from the convention, that the newly drafted Constitution established a system that was impractical for the general governance of such a large country, especially because it would extend “essential benefits to all.”

There you have it in a nutshell.  The Congress has the power to enact the ACA, however flawed it may be.  Our dissident founders saw this coming over 225 years ago.  They didn’t like it any better than does the right-wing today.  But its constitutionality should not be in question unless one chooses to ignore the history of the debate that has been raging for over two centuries since that Constitution was ratified.

The ACA is flawed for many reasons – all of them related to the politics in this country, especially the enormous lobbying power of the health insurance companies, which are as inefficient and inept as any government bureaucracy ever was.  The ACA, when fully implemented, will leave 23 million Americans uninsured.  Along with many people, I don’t like the mandate that all people must be insured at a certain level or pay a penalty (though the penalty is small).  I understand, however, that the design of the ACA necessitates requiring coverage for all to make it possible for the insurance companies to provide reasonably-priced insurance for those who need it.

The Medicare-for-all proposal that I favored would not have had the sign-up problems that have plagued the ACA because Medicare exists and runs relatively smoothly for a program with about 50 million beneficiaries.  As a Medicare beneficiary, I rarely see a bill because all costs are paid either by Medicare or my supplemental insurance.  When I do receive statements, they come several weeks or months after I have received services, and are more statements of what has been paid than bills.  This is because I chose supplemental insurance that has no co-pays.

The greatest frustration I have with health care under Medicare is with the prescription drug benefit, which was begun by President George W. Bush.  To receive drug coverage, I am required to contract with a private health insurance corporation, which micro-manages the prescription drug decisions of my physicians, dictating what prescriptions will be covered for various medical conditions.

Any single-payer system would be easier to manage than the ACA, which requires the cooperation of private insurance corporations in much the same way as the Medicare drug program.  But there were not enough votes in Congress to provide all Americans with the most sensible health-care insurance system.

As pointed out by that unnamed consumer advocate mentioned earlier, when Medicare was implemented in the 1960s, it enrolled 20 million people in six months using index cards, rather than computers – there was no internet in those days.  While has had internet technology problems, it is not alone in that regard.  Every entity, public or private, that uses the internet has had similar problems.  That’s why we have the new professional class called by the apt acronym IT.

If Canada is a good example, a single-payer system should not be tied to a person’s employer, or be complicated by an insurance company, by concern about corporate profits, by a person’s income level, by worries about using an “in-network” provider versus an “out-of-network” provider, by fear of bankruptcy due to health care costs, or by payment of deductibles and co-pays (though they may apply to supplemental coverage purchased by many Canadians, especially for dental, optometrist, and drug expenses).

Canada’s system covers everyone from birth to death and costs half what the health care system in the US costs because there are fewer administrative costs for the system managers, as well as the health care providers, most of whom are private practitioners.  Canada allows negotiation with drug companies for the best price for prescription drugs, unlike the ACA and Medicare, a procedure that keeps drug costs under control while still returning fair profits to the drug manufacturers.

Like any system run by humans, the Canadian system is not perfect.  But it has better results than those we have in the US.  The one place where the US has better results is in the waiting time to see specialists or for elective surgery, but Canada is meeting its goals in this area about 75% of the time according to a 2010 report by the Commonwealth Fund.  (However, because of insurance requirements and the doctor’s workload, when I needed back surgery earlier this year, it took ten weeks to go from the onset of symptoms to surgery, not an outcome that met my medical needs.)  Nevertheless, a sizable majority of Canadians support their system according to a 2011 Gallup poll which found that 57% of Canadians were satisfied or very satisfied with Canada’s health care system – Americans report only 25% satisfaction with our health care system.

Canada pays for its health care system with a 6% tax on those in the lowest 20% income bracket and 8% for the 20% in the highest income bracket.  By contrast, in the US, the poor pay a higher percentage of their income on health care than do the wealthiest Americans.

The World Health Report ranks the US as 37th in health care performance.  That doesn’t seem exceptional.  As an article in the New England Journal of Medicine pointed out, “. . . in 2006, the United States was number 1 in terms of health care spending per capita but ranked 39th for infant mortality, 43rd for adult female mortality, 42nd for adult male mortality, and 36th for life expectancy.”

The ACA is ridiculously cumbersome and expensive to administer and fund, and the likelihood of its changing the quality of care Americans receive is nil, but our political system will not permit a better system right now, thanks to the right wings of both major political parties, and especially to the Tea Party faction in the Republican Party.

As conceived by most of the founders, the Constitution permits the ACA, even if it is an abomination.  Responsible politicians would work for a better, more efficient, and less costly solution to the health care needs of the people.  Our founders who signed the new Constitution in 1787 certainly expected better outcomes than we have obtained.

If we had a single-payer system for all in the US, everyone could have the same experience I enjoy when I go to my primary care physician.  I am asked, “What are you here for today?” not “What kind of insurance do you have?”

© Lamar W. Hankins, Freethought San Marcos

LAMAR W. HANKINS is a former San Marcos city attorney.

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One thought on “Freethought San Marcos: The debates of 1787 foreshadowed today’s health care debate

  1. I do not know if a syllable of Counselor Hankins article is true. What I do know is that I will look at ACA entirely differently in the future as a result of having read this article. Good job Counselor and keep up the good work.

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